The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

Disturbed personal identity.

Risk for injury.

Ineffective coping.

Anxiety, panic.

Answer and Explanation

The Correct Answer is B

A) Disturbed personal identity could be relevant in the context of a mental health issue, but it is not the most immediate concern given the client's current presentation. While it may be important to address over time, it does not take precedence in the acute phase.

B) Risk for injury is the most critical problem to include in the client's plan of care. The client's lack of sleep, pressured speech, and increase in sexual promiscuity indicate a potential manic episode, which can lead to impulsive and unsafe behaviors. Prioritizing the risk for injury ensures the safety of the client and others, making it essential for the immediate care plan.

C) Ineffective coping is a concern that may develop in response to the client's current symptoms. However, addressing immediate safety needs is more urgent than focusing on coping mechanisms at this point.

D) Anxiety and panic might be present, but they are not as clearly defined in the client's current symptoms as the risk for injury. The focus should remain on preventing harm and ensuring the client is safe during this acute episode.

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Correct Answer is A

Explanation

A) Reviewing serum creatinine is the most critical laboratory finding prior to initiating lithium therapy. Lithium is primarily excreted through the kidneys, and any existing renal impairment can increase the risk of lithium toxicity. Ensuring normal kidney function is vital for safe lithium administration and monitoring throughout the treatment.

B) While blood glucose levels can be relevant in the context of overall health and any potential metabolic syndrome concerns, they are not as directly related to lithium therapy as renal function. Blood glucose levels do not significantly impact the safety or effectiveness of lithium.

C) A white blood count (WBC) can be important in assessing for potential infections or hematological disorders, but it is not the primary focus when starting lithium. Lithium does not typically have a direct effect on white blood cell levels, making this finding less critical compared to renal function.

D) Alkaline phosphatase levels are primarily related to liver function and bone health. While monitoring liver function is important in general, it is not as directly pertinent to the initiation of lithium therapy as assessing renal function through serum creatinine levels. Therefore, this laboratory finding is less of a priority in this context.

A. Explains answers to open-ended questions. B. Reports enjoyment from assigned activities. C. Shares a personal story with peers. D. Performs activities of daily living.

Correct Answer is D

Explanation

(A) Explains answers to open-ended questions:While explaining answers to open-ended questions indicates cognitive engagement, it does not directly address avolition, which is characterized by a lack of motivation to perform purposeful activities.

(B) Reports enjoyment from assigned activities:Reporting enjoyment from activities is a positive sign, but it does not necessarily indicate an improvement in the motivation to initiate and complete tasks independently.

(C) Shares a personal story with peers:Sharing personal stories can demonstrate social engagement, but it does not directly reflect an improvement in avolition, which involves the motivation to perform daily tasks.

(D) Performs activities of daily living:Performing activities of daily living (ADLs) demonstrates an improvement in avolition, as it shows the client is motivated to take care of themselves and engage in necessary daily tasks. This behavior directly aligns with the goal of improving avolition.

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The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes lithium carbonate for a client diagnosed with bipolar, manic depression. It is most important for the nurse to review which laboratory finding prior to beginning the drug therapy?

Correct Answer is A

Explanation

The mental health team working with a homeless client with chronic schizophrenia establishes the treatment goal of, "Improvement in avolition prior to discharge." Which behavior demonstrates achievement of this goal to the nurse?

Correct Answer is D

Explanation

A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

Which goal has the highest priority for an adolescent client who is hospitalized for weight loss related to anorexia nervosa?

A young adult client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?

A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from responsibilities, and describes an inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care?